Posts Tagged ‘Low Back Pain’

Some time ago I set myself a goal to write up case studies based on the positive results that have I seen in my practice. Like every Chiropractor I get excited when I hear of life changing turnarounds in a wide range of health complaints. And not always because that person first consulted me with “Condition X” – they may come to me with the garden variety neck and back ailments. But then weeks later the person shares their story of healing and improved quality of life since starting to see me.

Well you might say I have opened a can of worms because the reality of “writing up” has been daunting: A clear history, examination findings and having some sort of outcome measure in place so that after those weeks of adjustments you can say for real that signs and symptoms have diminished – the objective before and after as opposed to the testimonial. And then there is the challenge of writing up an introduction and discussion of the condition in question – requires literature research and time.

So retrospectively I began to dig out files of my fondest case memories and quickly discovered that I did not have much more to go on than a testimonial. Child was a bed wetter – now they aren’t, teenager had reduced asthma medications and number and severity of attacks but no actual numbers to go along with those subjective observations, person who attended for low back pain and was then able to become pregnant after being adjusted (why didn’t they tell me they were infertile when they presented?), a parent stating that their child’s ADHD had significantly improved but now I have the challenge of finding out of their academic and social performance has improved – where to start?

I had been haunted by the words of an “old-timer” chiropractor at a Dynamic Growth Congress years before. He asserted that you “never ask your patients how they are – you tell them!” How do you do that? Now I know that we get to know our practice member’s bodies and that we can to a degree sense where they are at – but that intuition wasn’t quite enough for me – I wanted tools to measure where someone was in their functional journey. I’ve never been a dedicated user of Xrays and biomechanical lines and would always prefer non-invasive technologies so I began searching. The first purchase I made somewhere in the mid-nineties was software to analyse posture (www.torquerelease.com.au/Posture-Pro-Software.htm) and to come up with some objective calculations – cool tool and patients love the before and after pictures – a win-win. Back then this type of software cost thousands. This was in the days when computers were like old-age pensioners – took half the morning to warm up, and then didn’t do much after lunch. And we had to buy excessively expensive cameras that had a removable floppy disc – remember what those were? I envy today’s chiropractors who can pick up the latest version of this software for less than a grand, and download and install it on their high-speed notebook, and already have the camera that connects wirelessly.

Next I took out a five-year lease to get my hands on an Insight Subluxation Station (www.subluxation.net.au) and discovered that surface EMG, thermography and inclinometry were awesome tools for me to see if I was making the physiological changes that I hoped my adjustments produced. Boy was this confronting as I was forced along a pathway of finding better ways to deliver better adjustments and advice. I think we Chiropractors have had it too easy for too long because the only quality assurance that we have had to answer to is customer satisfaction. I remember one of my associate Chiropractors who was notorious for bypassing initial and progress exams, who when confronted stated that he didn’t see the point in using the measurements when they didn’t change! I guess my conclusion had been different as my revelation was that maybe I had to find the best ways for making positive changes – After all if a spine isn’t better aligned, more flexible and surrounded by less muscle tension after a series of adjustments, then what has been the actual benefit of those adjustments?

My next revelation was that I needed better outcome measures in my practice for a range of health concerns: If someone consults me and they suffer with migraines then I need to be able to demonstrate that the improvements in the sEMG, posture, thermography and range of motion are matched by measurable improvements in the regularity and severity of the signs and symptoms of migraine – sounds simple – just visit outcomemeasures.? to download the free tools I hoped? Not! My fantasy was a file of severity questionnaires that could be accessed depending on the name of the presenting dis-ease. So I contacted the academics and was told that such standardized and validated tools did exist. Next step was to find them… Still looking! Here’s the problem – they all have different completion and rating systems, most aren’t free or at least accessible, and regardless of whether they are scientifically validated few have been designed by chiropractors, for chiropractic – what is the point of a headache questionnaire that lacks a question about neck pain or dysfunction, or a low back questionnaire that fails to note any associated gastrointestinal or genitourinary signs? Since this time I have been gradually authoring my own range of health questionnaires – as I encountered a different health syndrome in practice, I would spend hours researching and then listing the “top twenty” associated signs and symptoms which would then be pasted into my template – each having exactly the same rating and format (www.torquerelease.com.au/Health-Questionnaires.htm) . Now these aren’t validated research tools but I love them for the power that they offer in terms of being able to take a subjective snapshot in time.

Nowadays I am in a newer practice and while designing my new systems I spent numerous hours (internet) searching for the best outcome tools out there: They had to be affordable, simple to use, and easy for the practice member to comprehend. After much shopping I combined Posture Pro, with digital photographic range of motion analysis software, Heart Rate Variability (www.torquerelease.com.au/emWave.htm) , along with the Torque Release Technique Indicators of Subluxation Scoring System that I had developed, and my Health Outcomes Questionnaires. Now I present my practice members with what I call their Spinal Functional Age (SFA) and Self-Perceived Health Age (SPHA).

The next barrier was in getting humans to follow the plan. I realised that my chances of producing legitimate case studies retrospectively were small. I needed to have a prospective plan: When Master Bedwetter, or Miss Asthma, or Mr Parkinsons or Mrs Multiple Sclerosis arrives at my rooms then I need the procedures in place so that I have sufficient pre-examination findings. Next challenge is to achieve sufficient compliance with care that will result in the types of positive changes we aspire to. And step three is to conduct a progress examination that supplies the “evidence” that I crave which is going to look good in ink.

What I am trying to say here is that my initial urge to write up a simple case study that is of some value to the evidence-base has actually sent me on a path of research and development that I like to think is making me a better Chiropractor.

Have you ever watched an episode of Geoffrey Robertson’s Hypothetical? This famous legal shark draws together a diverse cross section of “experts” and then forces them through a hypothetical case scenario that pushes the ethical, moral and human boundaries. Entertaining and usually enlightening viewing. To a point I believe it is valuable to apply this principle in our practice development pathway.

So, how does MY hypothetical influence YOUR life in practice? Ask yourself these questions:

1) Is your initial intake process thorough and objective enough that you could present clear evidence of what it is you are setting out to change for that person?

2) Do you have objective measurement tools to demonstrate how much this person’s functional status needs to change and whether you will have been able to initiate a change in their health concern?

3) Do you conduct a progress or review exam to measure whether you are achieving your shared goals?

4) Have you had the guts to put your technique to the objective litmus test across your entire practice population and not just your favourite miracle cases?

5) Do you have enough evidence to contribute a Case Study for the advancement of the Chiropractic Evidence Base?

When I present the stats from my own practice I show the average functional changes that occur and share the journey I have had to follow to ensure that I consistently generate significant objective improvements. At one seminar a Chiropractor pulled me aside during a refreshment break, and with a concerned look on his face stated that the changes I had documented were not very BIG. “Oh really” I said “how big are the changes that you are seeing?” “Well I don’t know” he said “but I know that they would be better than yours”. I almost envy his delusions of grandeur, but the reality is if you don’t know for sure, then you don’t know! My own research based on the functional tools that I currently prefer, suggest that one adjustment reduces someone’s functional age by one year. I personally think that is very significant – name any other healing method that can make someone one year younger in one visit?

There are a lot of modalities available to complementary health care professionals nowadays, and many claim significant benefits and often share testimonials of miraculous results. Whenever I check out a new technique the first question I ask is “how does it work?” The answer needs to follow some kind of logical and plausible physiological principles before I even ask the second question; “is there any research?” I have to be honest that I struggle with web-sites and marketing materials that are full of claims and stories, but lacking in rationale and evidence. Auriculotherapy is one method that has continued to impress and excite me, and for this reason it is one of the primary modalities that I offer in my own practice. This is the third in a regular update of recent research.

First let’s summarise the most recent findings:

1) Satisfaction in a wellness clinic: This study involved feedback from health professionals being given access to wellness services including Auriculotherapy once a week in the workplace. Most participants agreed or strongly agreed they felt more relaxed after sessions (97.9%), less stress (94.5%), more energy (84.3%), and less pain (78.8%). Ninety-seven percent (97%) would recommend it to a co-worker. Among surveys completed after five or more visits, more than half (59%-85%) strongly agreed experiencing increased compassion with patients, better sleep, improved mood, and more ease in relations with co-workers. Perceived benefits were sustained and enhanced by number of visits.

3) Chronic low back pain: This pilot study found that Auriculotherapy was safe and demonstrated additional clinical benefits when combined with exercise for people with chronic low back pain. This supports my own observation that the best treatment for low back pain is a combination of passive and active treatment.

4) Effect on inflammatory reactions: This study using animals showed that Auriculotherapy can increase serum Tumour Necrosis Factor and Interleukin-6, and down-regulate pulmonary NF-kappa B p 65 expression suggesting a cholinergic anti-inflammatory mechanism. This suggests a neurological pathway for antiinflammatory effects of Auriculotherapy which makes sense since Auriculotherapy is a neurological intervention!

5) Treatment of migraine attacks: This study compared using a reflex point well documented to relieve migraine (group A) versus a point unlikely to have a therapeutic effect (group B). During treatment, there was a highly significant trend in the reduction of symptoms in group A, whereas no significance was observed in group B. Symptoms were significantly lower in group A than in group B at 10, 30, 60 and 120 min after treatment. This study suggests that the therapeutic specificity of auricular points exists and is linked to the somatotopic representation of our body on the ear.

6) Analgesia and sedative effects during abdominal gynecological operation and effects on postoperative recovery of body function: This showed sedative, analgesic and function-regulating effects from Auriculotherapy. Anxiety was less, lower-doses of anaesthesia were required, breathing response was improved after the operation, and higher levels of serum beta-endorphin were found when Auriculotherapy was added. Anything that potentially improves surgical outcomes sounds like a really good thing to me!

7) Improving postural stability: Balance performance was measured on a force platform before and after Auriculotherapy. Main balance parameters pointed to an average short-term improvement of about 15% 1 hour after treatment and 5-10% after an interval of 3 days. However, a few participants showed a better than 30% improvement with the same parameters. The explanation tentatively put forward to account for the results was that Auriculotherapy reduces nociceptive interference and thus improves postural control.

Treating headache, trigeminal neuralgia and retro-auricular pain in facial palsy: In this study Auriculotherapy treatment showed pain alleviation in headache, trigeminal neuralgia, and retro-auricular pain levels. The researchers noted that treatment number should be no less than 10 sessions.

9) Preoperative anxiety treatment: Preoperative anxiety has become more frequent in preoperative patients and can bring negative impact on operation outcomes. The study concluded that Auriculotherapy was significantly effective in decreasing anxiety in preoperative patients.

Abstract Objectives: The objectives of this study were to examine the feasibility of a weekly on-site complementary and alternative medicine (CAM) wellness clinic for staff at a military hospital, and to describe employees’ perceptions of program effectiveness. Setting: The study setting was the Restore & Renew Wellness Clinic at a United States Department of Defense hospital. Subjects: The subjects were hospital nurses, physicians, clinicians, support staff, and administrators. Interventions: The walk-in wellness clinic was open 8:00am – 2:00pm 1 day a week. Participants selected one or more modalities each visit: ear acupuncture, clinical acupressure, and Zero Balancing. Outcome measures: A self-report survey was done after each clinic visit to evaluate clinic features and perceived impact on stress-related symptoms, compassion for patients, sleep, and workplace or personal relationships. Results: Surveys completed after first-time and repeat visits (n=2,756 surveys) indicated that most participants agreed or strongly agreed they felt more relaxed after sessions (97.9%), less stress (94.5%), more energy (84.3%), and less pain (78.8%). Ninety-seven percent (97%) would recommend it to a co-worker. Among surveys completed after five or more visits, more than half (59%-85%) strongly agreed experiencing increased compassion with patients, better sleep, improved mood, and more ease in relations with co-workers. Perceived benefits were sustained and enhanced by number of visits. The most frequently reported health habit changes were related to exercise, stress reduction, diet/nutrition, and weight loss. Conclusions: This evaluation suggests that a hospital-based wellness clinic based on CAM principles and modalities is feasible, well-utilized, and perceived by most participants to have positive health benefits related to stress reduction at work, improved mood and sleep, and lifestyle.

2) Brain-modulated effects of auricular acupressure on the regulation of autonomic function in healthy volunteers.

Auricular acupuncture has been described in ancient China as well as Egypt, Greece, and Rome. At the end of the 1950s, ear acupuncture was further developed by the French physician Dr. Paul Nogier. The goal of this study was to develop a new system for ear acupressure (vibration stimulation) and to perform pilot investigations on the possible acute effects of vibration and manual ear acupressure on heart rate (HR), heart rate variability (HRV), pulse wave velocity (PWV), and the augmentation index (AIx) using new noninvasive recording methods. Investigations were performed in 14 healthy volunteers (mean age ± SD: 26.3 ± 4.3 years; 9 females, 5 males) before, during, and after acupressure vibration and manual acupressure stimulation at the “heart” auricular acupuncture point. The results showed a significant decrease in HR (P ≤ 0.001) and a significant increase in HRV total (P = 0.008) after manual ear acupressure. The PWV decreased markedly (yet insignificantly) whereas the AIx increased immediately after both methods of stimulation. The increase in the low-frequency band of HRV was mainly based on the intensification of the related mechanism of blood pressure regulation (10-s-rhythm). Further studies in Beijing using animal models and investigations in Graz using human subjects are already in progress.

OBJECTIVES: To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP).

METHODS: Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) “Exercise Alone (E)”-12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) “Exercise and AA (EAA)”-12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire.

RESULTS: Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, -15.3,-5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, -11.4,-1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants.

DISCUSSION: Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.

4) Effect of electroacupuncture of auricular concha on inflammatory reaction in endotoxaemia rats.

Ear acupuncture can be a useful mean for controlling migraine pain. It has been shown that a technique called the Needle Contact Test (NCT) can identify the most efficacious ear acupoints for reducing current migraine pain through just a few seconds of needle contact. The majority of the points were located on the antero-internal part of the antitragus (area M) on the same side of pain. The aim of this study was to verify the therapeutic value of area M and to compare it with an area of the ear (representation of the sciatic nerve, area S) which probably does not have a therapeutic effect on migraine attacks. We studied 94 females suffering from migraine without aura, diagnosed according to the ICHD-II criteria, during the attack. They were randomly subdivided into two groups: in group A, tender points located in area M, positive to NCT were inserted; in group B, the unsuitable area (S) was treated. Changes in pain intensity were measured using a VAS scale at various times of the study. During treatment, there was a highly significant trend in the reduction of the VAS value in group A (Anova for repeated measures: p < 0.001), whereas no significance was observed in group B. VAS values were significantly lower in group A than in group B at 10, 30, 60 and 120 min after needle insertion. This study suggests that the therapeutic specificity of auricular points exists and is linked to the somatotopic representation of our body on the ear.

OBJECTIVE: To prove analgesia and sedative effect of adjuvant anesthesia with magnetic auricular point-sticking on abdominal gynecological operation and its effect on postoperative recovery of body function.

METHODS: Ninety-two patients with abdominal gynecological operation were randomly divided into 3 groups. The auricular point-sticking group (APS group, n=31) was pasted and pressed by plasters with magnetic beads at bilateral Shenmen, Pizhixia (subcortex), Zigong (uterus) and Penqiang (pelvic cavity), etc. the night before operation. The placebo group (n=31) was pasted by plasters without magnetic beads. The blank group (n=30) was given no intervention. The mental and gastrointestinal functional changes before and 3 days after the operation were observed.

The risk of falling is rather high among elderly people. Indexes obtained through the Romberg stabilometric test on a force platform have been suggested to be correlated with the risk of falling. This work aimed to test the effectiveness of auriculopuncture and ultralow-power laserpuncture versus placebo (sham stimulation) in improving postural control in an elderly population. Balance performance was measured on a force platform before and after both forms of stimulation. Main balance parameters pointed to an average short-term improvement of about 15% 1 hour after treatment and 5-10% after an interval of 3 days. However, a few participants showed a better than 30% improvement with the same parameters. Although the sample size does not allow reliable statistical analysis, the modifications are remarkable and some differences are observed between the two kinds of stimulation. Further testing with larger sized groups and including one further group using both stimulations is suggested. Although postural instability has to be defined as multi-factorial, it is often associated with balance dysfunctions that cannot be related to vestibular or central impairments but rather to proprioceptive deficits. A significant role may be ascribed to (even subliminal) nociceptive interferences with proprioceptive inputs and to a reduced capacity for updating cortical motor control models in the case of progressively declining locomotor capabilities. The explanation tentatively put forward to account for the results observed in the present preliminary study is that laser acupuncture and auriculopuncture stimulations reduce nociceptive interference and thus improve postural control.

Traditional acupuncture (TA) and ear acupuncture (EA) are used for treatment of headache, trigeminal neuralgia, and retro-auricular pain. The purpose of this study is to develop effective treatment using combined acupuncture (CA) which consists of TA and EA and to set clinical protocols for future trials. Participants were divided into TA (n = 15) control and CA (n = 34) experimental groups. Obligatory points among Korean Five Element Acupuncture and optional individual points along with symptom points were used in the TA group. The CA group was exposed to ear points of Fossion and TA. Acupuncture treatment consisted of six mandatory sessions per patient over 3 weeks and extended to 12 sessions. Pain was assessed using the visual analogue scale. We compared TA to CA and researched their relevant publications. No significant difference was observed between the two groups (p = 0.968) which showed pain-alleviating tendency. Pain alleviation was significantly different after the fifth and sixth sessions (p = 0.021, p = 0.025), with headache being the most significantly relieved (F = 4.399, p = 0.018) among the diseases. When assessing pain intensity, both the Headache Impact Test and the Migraine Disability Assessment Scale should be adopted for headache and the fractal electroencephalography method be used in pain diseases. In the future, studies should consist of TA, EA, and CA groups; each group having 20 patients. Treatment number should to be no less than 10 sessions. Korean Five Element Acupuncture should be a compulsory inclusion along with individual points being optional inclusion in TA. EA could be selected from Nogier, Fossion and so forth. In conclusion, acupuncture treatment, whether TA or CA, showed pain alleviation in headache, trigeminal neuralgia, and retro-auricular pain, but no significant difference was seen between groups. Prospective, well-controlled, and relevant protocols using multimodal strategies to define the role of TA, EA, and CA are needed.

BACKGROUND: Preoperative anxiety has become more frequent in preoperative patients and can bring negative impact on operation outcomes. Many studies have reported the effect of body acupuncture in reducing anxiety syndromes. The aim of this study is to compare the treatment effect of body acupuncture and auricular acupuncture in preoperative patients with preoperative anxiety.

METHODS: Thirty five elective ambulatory surgery patients were selected in the randomized and blinded trial. Subjects were randomly categorized in two intervention groups, the body acupuncture group who received acupuncture in the special points of body, and the auricular acupuncture group who received ear acupuncture. Zung Self-Rating Anxiety Scale (SAS) was used before and after the study.

RESULTS: For the auricular acupuncture group, the mean score of SAS was 57.57 ± 8.22 before the intervention and 46.32 ± 6.37 afterward. For the body acupuncture group, the SAS score was 55.39 ± 5.41 and 44.82 ± 6.76 before and after the intervention, respectively. For both groups, the difference between pre- and post-treatment scores reached the significant level (p = 0.00).

CONCLUSIONS: Both auricular and body acupuncture treatment methods were effective in decreasing anxiety in preoperative patients.